Documentation Issues

Based on the information you have learned in the course so far and the readings analyze the advantages and disadvantages of charting by exception when faced with a malpractice lawsuit. Discuss how you would correct mistakes in a medical chart and the formatting of your documentation when witnessing an adverse patient occurrence. How would these corrections be perceived in a court of law?

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Advantages and Disadvantages of Charting By Exception

Charting by exception can be a risky practice even if it does free up the nurse to provide more care to their patients. This practice does not provide incomplete documents but they are also not as complete as they could be since there is a lack of detail. The majority of the charting occurs when the patient’s condition changes and then the nurse has to be detailed and specific to these changes as well as responses to interventions (Nurses Service Organization, 2013). I was always a fan of charting by exception because I preferred to be at the bedside with my patients. I did; however, make occasional notes pertaining to the patients’ conditions so that there was documentation of how their days were progressing and how they were doing.

Correct Mistakes in a Medical Chart

In order to prevent errors in the medical records, there are a few things that a nurse should keep in mind (these apply to either written charting, electronic charting, or both):

• Write legibly
• Be objective; subjective commentary can get you in trouble
• Never label the patient or their behavior
• Document exact times
• Avoid gaps in the record
• Follow facility policies/procedures at all times
• Document adverse events immediately
• Document all patient teaching
• Document all medication, teaching, or activities the patient refuses
• Never erase, scribble out or use write-out for errors – follow the policy for correcting these errors (one line through entry with initials/time/date

This is a partial list but I think you get the idea. There are many things you must ensure you do so that your documentation does not leave you vulnerable to trouble.

Documentation of Adverse Patient Occurrence

As with any documentation there are some rules to follow in documenting adverse events. There are:

• State the Facts only: Only information you see, hear, or otherwise collect through your senses; be specific and do not label; use neutral language and avoid bias.
• Avoid value judgments
• Be accurate
• Document completely all the event, times, individuals involved, patient responses, etc.
• Be timely document as soon as possible and include the times and dates of all events.
• Do not chart in advance or too late after the event.
• Be specific about times and events when completing a late entry. (Di Leonardi, 2012).

References

Austin, S. (2011, April). Stay out of court with proper documentation. Nursing2014, 41(4), 24-29. Retrieved fromhttp://www.nursingcenter.com/lnc/cearticle?tid=1150680

Di Leonardi, B. C. (2012, June 1). Professional documentation: Safe, effective, and legal. AMN Healthcare Education Services. RN.com.Retrieved from http://www.rn.com/getpdf.php/2062.pdf?Main_Session=7004d8a3cd66957ac9aa36b371c05f1e

Nurses Service Organization. (2013). Charting by exception: The legal risks. Retrieved from http://www.nso.com/nursing-resources/article/68.jsp